January 19, 2017

Mary Stankos, RN, MJ, CPHQ, CPPS, Patient Safety Consultant, MAPS

Alexis M. LaPietra, DO

Medical Director EM Pain Management St. Joseph’s Healthcare System

MAPS Patient Safety Organization Promoting a Culture of Safety in a Protected Environment

An Illinois Health and Hospital Association company.

Member Benefits: Supports health care providers across the continuum of care Certified by AHRQ since 2010 Provides Legal privileges, confidentialities & PSES support Promotes peer learning & networking Delivers data analysis to members & RCA feedback Meets the required ACA Healthcare Insurance Marketplace

mandate 42 CFR 3.20 Member of the Coalition to Improve Diagnosis, and Alliance for

Quality Improvement & Patient Safety

Housekeeping:

- Please place your phones on mute

- Feel free to ask questions via the webinar

chat feature located in the lower left-hand portion

of your screen

- Today’s presentation will be recorded

- The presentation slides will be made available to

all attendees

- A CE survey will be sent to all registrants by

Tammy DeLeonardis following the event.

Welcome!

A Federally-Listed Patient Safety Organization

CE Info for Today’s Webinar By the end of today’s webinar, participants will be able to

Learning Objectives:

Discuss the current prescription opioid epidemic and the role providers play

Review evidence-based alternatives to opioids for acute and chronic pain in the ED

Evaluate the role of novel modalities

As the sponsor of this webinar, the Illinois Health and Hospital Association is authorized by

the State of Illinois Department of Financial and Professional Regulation (license number

236.000109) to award up to 1.0 hours of nurse continuing education credit for this

program.

This program has been approved by the National Association for Healthcare Quality for

1.00 CPHQ continuing education hours.

This activity meets the criteria of the Certification Board for Professionals in Patient Safety

for 1.0 CPPS CE hours.

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ALTERNATIVES TO OPIOIDS ALTOSM

Alexis M. LaPietra, DO Medical Director EM Pain Management

St. Joseph’s Healthcare System

I have no financial disclosures

Objectives

Discuss the current prescription

opioid epidemic and the role

providers play

Review evidence-based alternatives

to opioids for acute and chronic pain

in the ED

Evaluate the role of novel modalities

1.9 million

75%

51

18,893

Substance Abuse and Mental Health Administration (SAMHA) estimated

2.8 million seniors ABUSED opioids

in the past year

In 2014, 467,000 adolescents were current nonmedical users of pain reliever,

with 168,000 having an addiction to prescription pain relievers

http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.

“Opioid overdose deaths in the US resemble a new infectious disease”

Newscientist.com 19Jan2016

0

1

2

3

4

5

6

7

1990 2005 2010 2015

Death Rate Prescription Opioid OD

1990-2015

0

1

2

3

4

5

6

7

1983 1986 1989 1990

Death Rate HIV-AIDS

1983-1990

HIV-AIDS

1990 1995 2000 2005 2010 2015

Opioid Prescribing Habits vs. Prescription Opioid OD Deaths

Rx opioid DEATHS Rx Opioids

Europe

11.4%

Canada

0.6%

100% of the world’s hydrocodone

81% of world’s oxycodone

USA 5.1%

Dalal 2013

80 %

What can we do in the ER?

Addiction

Acute Pain

Feel Better

Opiates Alternatives

ALTOSM Alternatives to Opioids

Acute Pain Protocols

Renal Colic

Musculoskeletal Pain

Lumbar Radiculopathy

Migraine Headache

Extremity Fracture/Dislocation

Opioids are necessary……

……but they are not the solution for all pain

THINK before you prescribe

USE alternatives whenever possible

CARE about the patient

Talk about painful

Feodor Vassilyev G27P69 c 1707-1782

Case 1

MM is a 57 year old female who presents to the ED with severe LEFT flank pain and vomiting. She has h/o kidney stones in the past. PMHx: none, PSHx: none, NKDA, No med prior to

arrival

Toradol® 30 mg IV

1 L NS

Zofran® 4 mg IV

Case 1, continued

MM reports minimal pain relief and is still in distress. Next line therapy?

Morphine?

Patient received morphine 5 mg IV.

VERY minimal pain relief

She receives another morphine 5 mg IV + Zofran®

Pain is unchanged and she is vomiting

Case 2

JA 28 year old male presents with severe kidney stone pain. He has a history of kidney stone pain in the past and is in recovery for heroin addiction, 7 months clean.

Last time he has a kidney stone, he received morphine, he states it took him weeks to overcome the craving for heroin

Alternatives?

He asks if there is an alternative to morphine, he states at another facility they said “no” and he was torn between pain relief and a potential relapse.

Is there evidence to support the use of alternatives for kidney stone pain?

Intravenous Lidocaine

Intractable oncological pain Improved pain with fewer side effects, compared

to opiates alone

Little to no toxicity

Improved quality of life

Post-operative pain relief, meta-analysis Reduced pain at rest, with movement, and with

cough

No statistical difference in adverse events

Ferrini 2004 Vigneault 2011

Lidocaine for Post- Op Pain Cochrane Review

Immediately reduced pain

lasting up to 24 hours

Less opiates

Decreased LOS

Quicker bowel function return

Less nausea

No difference in rate of death, arrhythmia, toxicity, or other heart disorder

Moderate evidence that intravenous lidocaine has an impact on pain scores compared to placebo

Kranke 2015

Lidocaine vs. Morphine RCT Renal Colic

Lidocaine had lower pain scores compared to morphine at 5, 10, 15, and 30 minutes post-administration

No difference in adverse events

Solemanipour 2012

Adverse Events

IV Lidocaine

Perioral numbness 2.5%

Transient dizziness 8.3 %

Dysarthria 1.7%

Without side effect 87.5 %

Morphine

Hypotension 2.5%

Vertigo 1.7%

Nausea/Vomiting 9.1%

Without side effect

86.7 %

Solemanipour2012

Mechanism of action

Inhibits afferent sensory conduction

Analgesia

Paralyzes the ureter

Quicker stone passage?

Intravenous Lidocaine

Cardiac Monitor

1.5 mg/kg (200 mg/100 mL NS) over 10 minutes on a pump MAX 200 mg

EXCLUSIONS- Seizure or malignant arrhythmia

Take Home Point #1

Intravenous lidocaine is a safe and effective analgesic for renal colic.

Fastest Toilet 55 mph

Case 3

57 M presents with 2 days of acute low back pain after moving a sofa. Has tried ibuprofen once per day without much relief. He states oxycodone has helped him in the past.

PMHx- high cholesterol

NKDA

What’s the best treatment for him?

Acute Low Back Pain

Opioids are not first line, especially in the ED

Early opioids prescribing

Increase rate of MRI

Significantly higher medical costs

29% more likely to end up on chronic opioids

Friedman 2015 Lee 2016

Alternatives

NSAIDS

Tylenol®

Topicals

Lidoderm®, Voltaren®, Flector®

Trigger Point Injection

Muscle Relaxants

NSAIDs and Tylenol®

NSAIDs are effective No better with Oxycodone/APAP No better with Cyclobenzaprine

Analgesic ceiling ~400 mg/dose or ~1200 mg/day

NSAIDs work better with Tylenol® Tylenol® 1000 mg

Friedman 2015 Derry 2013 McQuay 2007 Seymour 1996

Topicals

Lidoderm® patches

Diclofenac gel improves pain associated with OA of the knee and musculoskeletal injuries

NNT 1.8

Galer 2004 Wadsworth 2016 Baraf 2011 Barthel 2010 Cochrane 2015

Trigger Point Injection Definition

Myofascial Trigger Points

Tension Headache

Tinnitus

Temporomandibular joint pain

Torticollis

Dommerholt 2006

Myofascial Trigger Points

According to the CDC in a 2009 report, myofascial pain of the back is the second most common cause of disability in working-age adults.

Myofascial pain effects an estimated 10% of the US population and is typically underdiagnosed in the ED as a cause of pain

MMWR Morb Mortal Wkly 2009 Wheeler 2004

Most Common Trigger Point Location

Roldan 2015

Trigger Point Injection

Indications

Palpable taunt band or nodule in skeletal muscle with referred pain

Palpation reproduces pain

Acute or chronic MSK pain

Contraindications

Cellulitis over target area

Anticoagulation

Allergy to local

anesthetic

Trigger Point Injection Equipment

0.5% bupivacaine without epi- 1-2 mL

+/- steroids

25 gauge needle

Alcohol swap

Band-Aid®

Consent

Infection, bleeding

Trigger Point Injection Technique

Take Home Point # 2

Most acute low back pain does not require opioids

NSAIDs + Tylenol® + Topicals Muscle relaxant may be necessary

Trigger Point Injections It’s a billable procedure

2,583 unique rubber ducks!

Case 4

57 M with chronic pain due to lumbar radiculopathy presents with an acute flare. He takes MS Contin® 100 mg PO BID and oxycodone 30 prn.

No focal neuro deficits but in severe distress.

Management?

Your Brain on Opioids

The neurochemistry of the brain changes when exposed to chronic opioids

More opioids does not equal better relief

Allodynia

Hyperalgesia

Chronic Pain

Opioid Tolerant Patients

NSAID + Tylenol®

Gabapentin 300 mg

Diazepam or cyclobenzaprine

Ketamine infusion + drip

Ketamine for Analgesia

Antagonizes NMDA receptor Sole agent for analgesia

Sub-dissociative dosing 0.3 mg/kg infusion

0.1 mg/kg/hour drip

Opioid sparing effect

No vital sign changes, no additional monitoring Galinski 2006 Motov 2015 Miller 2015

Ketamine

Intranasal

Safe in children

0.5 mg/kg MAX 50 mg/dose

MAX volume 1 mL/naris

No change in vital signs

Significant reduction in pain score

Easy to administer

Can re-dose

Works within 15 minutes

Andalfatto 2013 Yeaman 2013 Yeaman 2014 Shrestha 2016

Take Home Message #3

Ketamine can be used in conjunction with opioids or as a sole agent for analgesia in the emergency department for acute and chronic pain.

Intranasal administration is effective and easy.

Supported by ACEP and SAEM

Case 5 (last case)

23 M comes to ED for gluteal abscess. You are in the urgent care/fast track section. The abscess is LARGE. He has had them before and is pleading with you to “put me to sleep”!

What do you do?

Nitrous Oxide

Nitrous Oxide

Tasteless colorless gas administered in combination with oxygen via mask or nasal hood Maximum concentration 70% N2O

Absorbed via pulmonary vasculature and does not combine with hemoglobin or other body tissues

Rapid onset and elimination <60 seconds

Becker 2008

Benefits of Nitrous Oxide

Analgesic and anxiolytic agent Use along with local anesthetic or other pain

medications

Releases enkephalins, effects reversed with naloxone

Only monitoring is pulse oximetry

No NPO requirements, patient can drive after administration, no IV line needed

Babl 2015 Zhang 1999

Becker 2008 Champman 1979

Nitrous Oxide Evidence

It indicated for any and every painful condition

All ages

Laceration

Lumbar puncture

Peripheral and central venous access

I&D

FB removal

Burn/Wound Care

Fecal Disimpaction Herres 2015 Ducasse 2013 Klomp 2012 Aboumarzouk 2011 Furuya 2009 Atassi 205

The Downside to Nitrous Oxide

Abuse potential

Mobile unit

Patient or nurse must hold mask

Patients may feel claustrophobic when using the facemask

Contraindications

COPD or severe active asthma

Severe vitamin B12 deficiency

Otitis Media, Sinusitis

Bowel Obstruction

Altered level of consciousness

Psychiatric disease, EtOH, Head Injury

1st and 2nd trimester pregnancy

Take Home Point #4

Nitrous Oxide is a fast acting easily administered analgesic, ideal for the management of acute pain

Summary

Renal colic IV LIDOCAINE

Low Back Pain Tylenol®, NSAIDs, topicals

and Trigger Point Injection

Opiate Tolerance KETAMINE

Procedures NITROUS

ALTOSM results

N= 1600 patients

47.6% reduction in opioids for acute low back pain, renal colic, and headache p= 0.0001

Pain scores pre-ALTO 8 1.9

Pain score post-ALTO 7.9 2.0

Keep exposure to a minimum

The use of alternatives for pain management

decreases unnecessary exposure of potential harmful medications to our patients.

Opioids are important but should not be reflexively prescribed

Dr. Shroff says “I’ve gone 3 shifts without prescribing any Percocet®, people are happy and have had great pain relief”

ALTOSM Partnerships

Departments

Physical Therapy

Family Medicine

Psychiatry

Pain Management

ALTOSM Partnerships

St. Joseph’s Opioid Overdose Prevention and Naloxone Distribution Program

Opioid Overdose Recovery Program

49% of patients approached enrolled in recovery

Straight and Narrow Program

Coming soon…

Suboxone® induction in the ED

Acupuncture for pain management in the ED

EDUCATE

Multidisciplinary approach

Prevention is KEY! Keep opioid naïve patients opioid free Utilize alternatives when possible

Collaborate with outpatient physicians

Reserve opioids as rescue medication NOT first line

Support patients who suffer from the DISEASE of addiction

If you’d like to know more

Join the ACEP Pain Management Section

lapietra@sjhmc.org

THANKS

THANK YOU!

We look forward to seeing you at

future MAPS PSO events.

For questions, contact

MAPSHelp@team-iha.org or

630-276-5657

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